Learning Healthcare System Principles to Facilitate Spread of DCR

  • Kara McElvaineEmail author
  • Joe C. McCannon
  • C. William Schwab


The fields of healthcare and public health regularly generate new innovations and evidence-based practices designed to alleviate suffering, improve quality of care, and help systems to function more efficiently. But while there is no shortage of well-established ideas about how to improve performance, disseminating what works remains a challenging and, at times, elusive enterprise. Adopting the principles of a learning healthcare system (LHS) can create an engine for embedding research-based and evidence-supported interventions and practices like Damage Control Resuscitation (DCR) into clinical care. An important facet of DCR is the need to bring it to the patients most in need and at an early interval after life-threatening injury and exsanguination. Thus, we address how different components of the trauma LHS (prehospital, en route, and in-hospital care) must integrate data, experience, and report outcomes to continuously learn, identify gaps, and direct further research and improvement. Prior to concluding, the chapter will briefly look at what it might take to introduce DCR at national scale.


Learning healthcare system Empowering clinicians Adaptation Data-driven decision-making Managing fear Quality improvement Spread of innovations Tests of change Leadership Measurement and data systems 


  1. 1.
    Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In: van Bemmel JH, McCray AT, editors. Yearbook of medical informatics 2000: patient-centered systems. Stuttgart: Schattauer Verlagsgesellschaft mbH; 2000. p. 65–70.Google Scholar
  2. 2.
    Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104:510–20.CrossRefGoogle Scholar
  3. 3.
    IOM (Institute of Medicine). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.Google Scholar
  4. 4.
    Norton WE, McCannon CJ, Schall MW, Mittman BS. A stakeholder-driven agenda for advancing the science and practice of scale-up and spread in health. Implement Sci. 2012;7:118.CrossRefGoogle Scholar
  5. 5.
    American College of Surgeons. America’s incomplete trauma system [Internet]. Chicago: American College of Surgeons; 2014 [cited 2018 May 27]. Available from:
  6. 6.
    Eastman AB, MacKenzie EJ, Nathens AB. Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health care needs. Health Aff. 2013;32(12):2091–8.CrossRefGoogle Scholar
  7. 7.
    IOM. Best care at lower cost. The path to continuously learning health care in America. Washington, DC: The National Academies Press; 2013.Google Scholar
  8. 8.
    Deming WE. The new economics: for industry, government, and education. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1993.Google Scholar
  9. 9.
    Williams DR, Wyatt R. Racial bias in health care and health: challenges and opportunities. JAMA. 2015;314(6):555–6.CrossRefGoogle Scholar
  10. 10.
    Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving health equity: a guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016. (available at
  11. 11.
    McCannon CJ, Margiotta BK. Carnegie summit keynote address. San Francisco: Carnegie Foundation; 2017 May [cited 27 May 2018]. Available from:
  12. 12.
    Mate K, Wyatt R. Health equity must be a strategic priority. NEJM Catalyst. 4 January 2017. Available from:
  13. 13.
    National Equity Project. Why equity? [Internet]. Oakland: National Equity Project [cited 2018 May 27]. Available from:
  14. 14.
    CDC. Chronic disease prevention and health promotion [Internet]. Atlanta: CDC [updated 2017 August 10. Cited 2018 May 27]. Available from:
  15. 15.
    Rogers EM. Diffusion of innovation. New York: The Free Press; 2003.Google Scholar
  16. 16.
    McCannon CJ, Massoud R, Alyesh AZ. Many ways to many. SSIR; 2016 October 20. Available from:
  17. 17.
    McCannon CJ, Berwick D, Massoud R. The science of large-scale change in Global Health. JAMA. 2007;298(16):1937–8.CrossRefGoogle Scholar
  18. 18.
    National Academies of Sciences, Engineering, and Medicine. A National Trauma Care System: integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press; 2016. Available from: Scholar
  19. 19.
    McCannon CJ, Perla R. Learning networks for sustainable, large-scale improvement. Jt Comm J Qual Patient Saf. 2009;35(5):286–91.CrossRefGoogle Scholar
  20. 20.
    Okun T, Jones K. White supremacy culture. In: Okun T, Jones K. A workbook for social change groups. 2001 [cited 2018 May 27]. Available at:
  21. 21.
    Ganz M. Leading change: leadership, organization, and social movements. In: Nohria N, Khurana R, editors. Handbook of leadership theory and practice: a Harvard Business School Centennial Colloquium: Harvard Business School Publishing Corporation; 2010. Chapter 19.Google Scholar
  22. 22.
    Ganz M. Public narrative, collective action, and power. In: Odugbemi S, Lee T, editors. Accountability through public opinion: from inertia to public action. Washington D.C: The World Bank; 2011. p. 273–89.CrossRefGoogle Scholar
  23. 23.
    Berwick D. Disseminating innovations in health care. JAMA. 2003;289(16):1969–75.CrossRefGoogle Scholar
  24. 24.
    Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining improvement. IHI white paper. Institute for Healthcare Improvement: Cambridge; 2016. (Available at Scholar
  25. 25.
    Intermountain Healthcare. Home page [Internet]. UT: Intermountain Healthcare [cited 2018 May 27]. Available from:
  26. 26.
    The King’s Fund. Case study 2: Healthcare. United Kingdom: The King’s Fund [cited 2018 May 27]. Available from:
  27. 27.
    Bohmer R, Edmondson A, Feldman L. Intermountain health care. HBR. 2013 March 18.Google Scholar
  28. 28.
    Rakover J. Sustaining improvement on the frontlines: the story of intermountain healthcare. Blog of Intermountain. Cambridge: IHI; 2016 August 16 [cited 2018 May 27]. Available from:
  29. 29.
    Blackmore CC, Mecklenburg RS, Kaplan GS. At Virginia Mason, collaboration among providers, employers, and health plans to transform care cut costs and improved quality. Health Aff. 2011;30(9):1680–7.CrossRefGoogle Scholar
  30. 30.
    Toussaint JS, Berry LL. The promise of lean in health care. Mayo Clin Proc. 2013;88(1):74–82. Available from: Scholar
  31. 31.
    Berry LL, Seltman KD. The enduring culture of Mayo Clinic. Mayo Clin Proc. 2014;89(2):144–7. Available from: Scholar
  32. 32.
    Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths. Jt Comm J Qual Patient Saf. 2006;32(6):299–308.CrossRefGoogle Scholar
  33. 33.
    Ball CG. Damage control resuscitation: history, theory, and technique. Can J Surg. 2014;57(1):55–60.CrossRefGoogle Scholar
  34. 34.
    Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control: an approach for improved survival in exsanguinating abdominal injury. J Trauma. 1993;35(3):375–82.CrossRefGoogle Scholar
  35. 35.
    Eastridge BJ, Hardin J, Cantrell L, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma. 2011;71(1):S4–58.CrossRefGoogle Scholar
  36. 36.
    Eastridge BJ, Mabry RL, Sequinn P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–7.CrossRefGoogle Scholar
  37. 37.
    Kwon AM, Garbelt NC, Kloecher GH. Pooled preventable death rates in trauma patients: meta analysis and systematic review since 1990. Eur J Trauma Emerg Surg. 2014;40(3):279–85.CrossRefGoogle Scholar
  38. 38.
    Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62:307–10.CrossRefGoogle Scholar
  39. 39.
    Spinella PC, Perkins JG, Grathwohl KW, et al. Fresh whole blood transfusions in coalition military, foreign national, and enemy combatant patients during Operation Iraqi Freedom at a U.S. combat support hospital. World J Surg. 2008;32(1):2–6.CrossRefGoogle Scholar
  40. 40.
    Spinella PC, Stradenes G. The trauma hemostasis and oxygenation research network’s remote damage control resuscitation symposium. Shock. 2014;41(Suppl1):1–2.CrossRefGoogle Scholar
  41. 41.
    Cannon JW, Khan MA, Rafa AS, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017;82:605–17. Accessed 22 May 2018.CrossRefGoogle Scholar
  42. 42.
    Lamb CM, MacGoey P, Navarro AP, Brooks AJ. Damage control surgery in the era of damage control resuscitation. Br J Anaesth. 2014;113(2):242–9.CrossRefGoogle Scholar
  43. 43.
    Cotton BA, Gunter OK, Isbel J, et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008;64:1177–82.CrossRefGoogle Scholar
  44. 44.
    Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598–605.CrossRefGoogle Scholar
  45. 45.
    Beekley AC. Damage control resuscitation: a sensible approach to the exsanguinating surgical patient. Crit Care Med. 2008;36(7Supp):S267–74.CrossRefGoogle Scholar
  46. 46.
    Langan NR, Eckert M, Martin MJ. Changing patterns of in hospital deaths following implementation of damage control resuscitation practices in the US forward military treatment facilities. JAMA Surg. 2014;149:904–12.CrossRefGoogle Scholar
  47. 47.
    McCannon J, Margiotta B, Zier Alyesh A. Unleashing large-scale change. SSIR. 2017 June 16 [cited 2018 May 27]. Available from:

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Kara McElvaine
    • 1
    Email author
  • Joe C. McCannon
    • 2
  • C. William Schwab
    • 3
    • 4
  1. 1.Oregon State UniversityCorvallisUSA
  2. 2.Billions InstituteCambridgeUSA
  3. 3.Perlman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  4. 4.Traumatology, Surgical Critical Care and Emergency SurgeryPenn Presbyterian Medical CenterPhiladelphiaUSA

Personalised recommendations